BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

AHFS Therapeutic Class Description Product Name Multi‐Source Code Formulary Tier Prior Auth Required Quantity Limits Specialty Product Formulary StatusOTHER MISCELLANEOUS THERAPEUTIC AGENTS ASTHMA RX TAB BRAND TIER 99 DEATROPINUM SUB COMPOSIT BRAND TIER 99 DEAUBAGIO TAB 14MG BRAND TIER 03AUBAGIO TAB 7MG BRAND TIER 03AURUM LIQ 12X GENERIC TIER 01AURUMHEEL DRO BRAND TIER 99 DEAVAILNEX CHW 750MG BRAND TIER 99 DEBEE VENOM INJ 1300MCG BRAND TIER 03BEE VENOM INJ 550MCG BRAND TIER 03BOTOX INJ 100UNIT BRAND TIER 03 PA SPBOTOX INJ 200UNIT BRAND TIER 03 PA SPBOTOX COSMET INJ 100UNIT BRAND TIER 03BOTOX COSMET INJ 50UNIT BRAND TIER 03CACTUS LIQ COMPOSIT BRAND TIER 99 DECALAFOL RX TAB BRAND TIER 03CARDIOVID CAP PLUS BRAND TIER 99 DECARNITOR INJ 1GM/5ML Brand‐O TIER 03 PACARNITOR SOL 1GM/10ML Brand‐O TIER 03 PACARNITOR TAB 330MG Brand‐O TIER 03 PACARNITOR SF SOL 1GM/10ML Brand‐O TIER 03 PACARTICEL IMP BRAND TIER 99 DECAT HAIR INJ EXTRACT BRAND TIER 03CERECOMP INJ BRAND TIER 99 DECHELIDONIUM LIQ COMPOUND BRAND TIER 03COENZYME INJ COMPOSIT BRAND TIER 99 DECOR COMPOSIT LIQ BRAND TIER 99 DECRALONIN DRO BRAND TIER 99 DECRALONIN LIQ BRAND TIER 99 DECUTIS COMPOS INJ BRAND TIER 99 DECYSTADANE POW BRAND TIER 02 SPCYSTAGON CAP 150MG BRAND TIER 02CYSTAGON CAP 50MG BRAND TIER 02DEMSER CAP 250MG BRAND TIER 02DEPLIN TAB 15MG BRAND TIER 99 DEDEPLIN TAB 7.5MG BRAND TIER 03DERMAGRAFT MIS BRAND TIER 03DERMATODORON LIQ BRAND TIER 99 DEDIGESTODORON LIQ BRAND TIER 99 DEDISCUS INJ COMPOSIT BRAND TIER 99 DEKey: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization, SP= Restricted to specialty pharmacy, QL= Quantity Limit, MO= Mail order eligible after one prescription fill at retail, DE= DrugExclusion208